Eliminating Inaccuracy and Unreliability in Hand Hygiene Monitoring: Moving to Electronic Systems to Improve Patient Safety

Staff - Wednesday, October 3rd, 2012

Hand hygiene is one of most critical factors in ensuring patient safety and quality in a healthcare organization. Thomas Diller, MD, MMM, vice president of clinical effectiveness and quality at Greenville (S.C.) Hospital System University Medical Center, and Heather McLarney, vice president of marketing at hand hygiene product supplier DebMed, discussed hand hygiene compliance in a recent webinar presented by Becker's Hospital Review. The webinar, titled "Lead the Change to Improved Patient Safety and Quality: Moving Beyond Direct Observation to Electronic Hand Hygiene Monitoring," revealed the differences between direct observation and electronic hand hygiene monitoring.

Direct observation vs. electronic monitoring

While many hospitals directly observe healthcare employees to ensure they clean their hands when necessary, the method has several weaknesses. Ms. McLarney shared the limits of direct observation and the benefits of electronic hand hygiene monitoring systems:

1. The Hawthorne Effect

Direct observation: In this effect, people act differently when they are being watched. In hand hygiene observation, this effect results in artificially high rates of compliance.

Electronic monitoring: The Hawthorne Effect is eliminated with electronic monitoring systems because people are not being watched by others.

2. Cost

Direct observation: As a manual process, direct observation is resource-intensive and time-consuming.

Electronic monitoring: Electronic systems improve efficiency and reduce costs associated with direct observation, product utilization or surveys because they are automated.

3. Timeliness

Direct observation: After monitors complete their observation, it takes time to calculate compliance rates. By the time these rates are calculated, it may be too late to influence behavior, Ms. McLarney said.

Electronic monitoring: Electronic systems can capture hand hygiene data in real time and can generate reports on compliance rates immediately.

4. Sample size

Direct observation: Hand hygiene monitors can only observe a portion of the hospital's total workforce. According to a study by the University of Iowa presented at the 21st Annual Scientific Meeting of the Society for Healthcare Epidemiology of America in 2011, monitors may see only 1.2 to 3.5 percent of all hand hygiene opportunities, according to Ms. McLarney. The small sample size can result in very low statistical reliability of compliance rate results, she said.

Electronic monitoring: Electronic systems can capture 100 percent of hand hygiene events, because sensors in sanitizer dispensers send data back each time the dispenser is used.

5. Observer bias

Direct observation: Observers may not be properly trained in monitoring hand hygiene compliance. In addition, they may have a positive or negative bias that affects the results.

Electronic monitoring: Electronic systems standardize hand hygiene reporting and increase accuracy.

Case study: Greenville Hospital System University Medical Center

Greenville Hospital System University Medical Center initially used unit self-audits to determine hand hygiene compliance, and found that compliance rates were routinely between 95 and 99 percent. The system then used a secret shopper method, in which a few monitors observed employees without their knowledge, and found compliance was actually 53 percent. The secret shopper method is not very sustainable, however, due to its costs in time and resources, so the hospital system turned to electronic monitoring.

One of the most important features of the electronic system, according to Dr. Diller, was that it monitored the "Five Moments for Hand Hygiene" as defined by the World Health Organization. These moments are before patient contact, before an aseptic task, after body fluid exposure risk, after patient contact and after contact with patient surroundings. Including all five moments in hand hygiene compliance rates gives a more complete picture of compliance than simply monitoring hand cleaning before and after touching a patient.

For example, Dr. Diller said one hospital in the Greenville Hospital System had an outbreak of vancomycin-resistant enterococcus. A large source of the bacteria was the pull curtains. A nurse could wash his or her hands before seeing a patient, close the curtain and get infected; treat the patient and then clean his or her hands. The rate of compliance for only "in and out" situations would be high, but rates would be low when taking into account the other three moments.

Accurate hand hygiene monitoring can help guide hospitals' hand hygiene efforts, which can reduce infections. "Hand hygiene was integral to the overall effect of a substantial decrease in infection rates over the last three to four years," Dr. Diller said.

View or download the Webinar by clicking here (wmv). We suggest you download the video to your computer before viewing to ensure better quality. If you have problems viewing the video, which is in Windows Media Video format, you can use a program like VLC media player, free for download by clicking here.

Download a copy of the presentation by clicking here (pdf).